The Outpatient Ophthalmic Surgery Society (OOSS) and ophthalmic ASCs concluded a successful year in 2024 in meeting our regulatory and legislative objectives. We will enjoy in 2025 our 26th consecutive year of positive annual payment rate updates. Working with the other ophthalmology organizations, we persuaded Medicare carriers to reverse its Local Coverage Determination (LCD) substantially limiting payment for MIGS procedures. Moreover, we staved off for at least a couple more years payment for in-office cataract surgery. Below, I highlight some of these successes and the challenges we face in a significantly altered political climate.
2025 ASC payment rates and beyond
Under the final rule, ASC payment rates will be updated by 2.9% in 2025 (reflecting the hospital market basket index of 3.4% less the MFP adjustment of 0.5%). As noted above, the update represents an average across all ASC procedures.
Five years ago, the Center for Medicare and Medicaid Services (CMS) agreed, for the period 2019-2023, to update ASC payment rates by the Hospital Market Basket rather than the lower Consumer Price Index-Urban. OOSS has been a leader in the effort to effectuate this change for more than 20 years, seeking to persuade both CMS and Congress of its merits. Under this policy, ASCs have received the same update as hospitals, subject to certain adjustments. The policy was supposed to come up for review in 2024.
However, because of data problems associated with the pandemic, the agency last year extended the application of the Hospital Market Basket to ASCs through 2025. OOSS will continue to strenuously recommend that CMS maintain permanently the application of the Hospital Market Basket in computing the annual ASC payment update.
ASC quality reporting
The agency is not proposing to remove any ASC quality measures. Regrettably and over the objections of the ASC and ophthalmology communities, CMS has not repealed the misguided and administratively burdensome quality measure requiring facilities to report on patient visual function 90 days after cataract surgery. Importantly, the measure will remain voluntary indefinitely.
For the past several years, OOSS and the ASC and ophthalmology communities have been engaged in the process of developing and proposing new and appropriate ophthalmic ASC measures. The agency adopted in 2019 a new ophthalmic quality measure, ASC 14: Unplanned Anterior Vitrectomy, which assesses the percentage of cataract surgery patients who have the procedure in an ASC. We will continue to recommend implementation of an ASC quality measure for TASS.
CMS has added three new quality measures to the ASC Quality Reporting Program:
- Facility Commitment to Health Equity (FCHE) measure — beginning with the CY 2025 reporting period/CY 2027 payment determination. Reporting will be voluntary in 2025 with mandatory compliance in 2026 and payment determinations in 2028. Facilities must submit annual attestations on their performance across these domains: equity as a strategic priority, data analysis, quality improvement and leadership engagement. Although the measures are not tied to direct financial penalties, compliance is required to maintain program eligibility without payment reductions.
- Screening for Social Drivers of Health (SDOH) measure — beginning with voluntary reporting in the CY 2025 reporting period followed by mandatory reporting beginning with the CY 2026 reporting period/CY 2028 payment determination. These determinants include food, housing, interpersonal, and transportation insecurities as well as utilities.
- Screen Positive Rate for Social Drivers of Health (SDOH) measure — beginning with voluntary reporting in the CY 2025 reporting period followed by mandatory reporting beginning with the CY 2026 reporting period/CY 2028 payment determination. This measure assesses a facility’s ability to identify health-related social needs in patients.
Moreover, in the proposed ASC payment rule, CMS requested public comment on the “potential development of frameworks for specialty focused reporting and minimum case number for required reporting under the ASCQR Program.” This could potentially reduce the administrative burden on ophthalmic ASCs by limiting requirements that our centers report on measures that are not relevant to our patient population or the services we provide.
To say the least, these measures provide potentially onerous operational challenges for facilities. Do not despair. Working with other societies, OOSS will be lobbying the new administration to withdraw or significantly modify these requirements.
Local coverage determinations regarding MIGS and related procedures
In September 2023, all the Part B Medicare carriers issued LCDs encompassing significant payment limitations on MIGS and other related procedures. Based on lobbying efforts of OOSS, AAO, AGS and ASCRS, the carriers have since withdrawn most of these limitations. Our work is not yet concluded. The MACs still will not currently pay for combination MIGS procedures and aqueous shunt at the same time of service in the same patient. Phaco can be performed with a single MIGS procedure, but multiple procedures (e.g., stent and MIGS surgical procedure) cannot be performed in the same eye at the same time.
Office cataract surgery
Last year, CMS issued its final Medicare Fee Schedule/Physician Payment rule. The agency did not address the issue in the 2025 physician payment rule. In a victory for our patients and our ASCs, CMS has continued to reject proposals by promoters of office surgery to make facility payments for office cataract and other ophthalmic surgeries.
For a decade, OOSS has absolutely and unequivocally opposed payment for office cataract surgery until such time as they meet patient health and safety standards comparable to those required in ASCs. With other ophthalmology and ASC organizations, OOSS has repeatedly raised myriad patient health and safety concerns with federal health policy makers. We developed a comprehensive comparison of Medicare ASC requirements vs office surgery standards, leading to the conclusion that patient health and safety is potentially compromised in the office setting. OOSS submitted comprehensive comments to CMS objecting to office cataract surgery reimbursement; kudos to the many OOSS members who submitted individual comments to the agency!
OOSS conducted a comprehensive survey with input from hundreds of ophthalmic ASCs regarding the comorbidities associated with cataract patients, the results of which highlighted the need for application of rigorous patient health and safety standards, such as anesthesia and nursing care and emergency capabilities and hospital transfer arrangements. Such mandates rarely apply in the unregulated office surgical suite.
The issue will be considered by CMS as part of the RUC review commencing in 2025, which means that, at the very earliest, payments for OBS could commence in 2027. This said, I do not believe that CMS will grant Part B facility reimbursement to office cataract centers until such time as peer-reviewed clinical literature supports the safety and efficacy of OBS; the major ophthalmology organizations support payment for OBS; and, until appropriate standards for patient health and safety are established by CMS, state regulators, and/or private accreditation entities.
Final thoughts
Despite our successes on the legislative and regulatory fronts, we face innumerable challenges. I urge you to continue to support OOSS and to be active in our grassroots lobbying initiatives. In deciding whether to so engage, please ask yourself these questions: In the absence of OOSS’ work over these past four decades, could surgeons still own and refer their patients to ASCs? Would our facility payments have increased by 350% or would they have declined like professional fees? Would we be able to perform and be paid for virtually every ophthalmic procedure in the ASC? Would Medicare ASC facility regulations be more burdensome, threatening the very viability of the OASC? OASC
